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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197700105
Report Date: 02/07/2022
Date Signed: 02/07/2022 04:52:33 PM

Document Has Been Signed on 02/07/2022 04:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:MARTINEZ FAMILY CHILD CAREFACILITY NUMBER:
197700105
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 23CENSUS: 8DATE:
02/07/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:04 PM
MET WITH:Virginia MartinezTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA)Isabel Ortega conducted a Case Management- Plan of Correction (POC) in person inspection at the above facility to verify Florencia Cox Calbac is not at the facility. Upon arrival LPA was greeted by licensee, Virginia Martinez.

During today's inspection LPA observed 8 children in care, licensee and one Assistant (fingerprint cleared and associated). LPA did not observe uncleared staff at the facility today. POC has been cleared.

The licensee was informed the presence of any adults in the home without Criminal Record Clearance or Exemption and not associated to facility will be cited and civil penalty assessed for $100 per day. The licensee may find additional information and forms on the DSS website at www.ccld.ca.gov. Licensee stated Florencia Cox Calbac is no longer employed at this facility. LPA provided LIC508, Live Scan/Finger print application (LIC 9163) in English and Spanish also informed licensee immunization, Mandated Reporter Training and CPR/First Aid are also required for any adult left alone supervising children.

An exit interview was conducted, a copy of this Report, Appeal Rights, and Notice of Site Visit were provided to licensee Virginia Martinez on this day.

SUPERVISORS NAME: Carissa Bell
LICENSING EVALUATOR NAME: Isabel Ortega
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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